Provider Demographics
NPI:1609532720
Name:GORDON, MADELINE M
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:M
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2552
Mailing Address - Country:US
Mailing Address - Phone:215-932-3748
Mailing Address - Fax:
Practice Address - Street 1:775 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-5143
Practice Address - Country:US
Practice Address - Phone:603-625-6198
Practice Address - Fax:603-625-2045
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH080401-21163W00000X
NH080401-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse